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As I was drowsily typing notes recently during an otherwise quiet afternoon in the medical intensive care unit, the resounding call on the overhead speaker snapped me awake: “CODE BLUE! Ground floor imaging suite. CODE BLUE!”
As the intern admitting patients that day, I also held the responsibility of serving as a first responder at every Code Blue — a medical term meaning that a patient is in need of immediate help, often due to a life-threatening emergency.
A crowd of various medical staffers quickly gathered in the small room where an elderly man, Mr. R, had unexpectedly lost his pulse while undergoing a CAT scan. For several minutes, the patient endured multiple rounds of rib-breaking thrusts to his chest to restart his heart.
Then, suddenly, a nurse who had been reading through his medical chart screamed, “This man has an advanced directive from six years ago that says he does not want resuscitative measures!”
Nearly all the heads in the room turned, many staffers confused as to whether to continue the resuscitation. The advanced directive is a legal document that records a patient’s preferences for medical care in case communicating them is impossible. In most cases, a "do not resuscitate" order alone might stop a medical team from pursuing further intervention.
But this man, unlike many patients in the intensive care unit who were clearly close to dying, had walked into the hospital for an elective diagnostic work-up. As of that morning, he was not close to dying, and even within moments of starting CPR, we felt reasonably certain that we could resuscitate him.
My senior resident astutely directed me to figure out who Mr. R had listed as his health care proxy, his stand-in medical decision-maker. We needed to make sure that Mr. R would not want us to do any more.
The proxy was his son, who lived in another state. When I called to check about his father's wishes, his answer was unequivocal: "My father would want everything done to save his life."
Minutes later, we regained a pulse and Mr. R was sent to the intensive care unit, where he was temporarily intubated on a ventilator for a few hours. After he was weaned from the ventilator, he looked at me and said, “Thanks, doc. If it weren’t for you guys, I wouldn’t have made it to today.”
I asked him again about whether he would want to be resuscitated or intubated if needed to keep him alive. He said he would, so long as it would not mean a life permanently dependent on a machine.
He walked out of the hospital two days later, knowing that he had almost died. What he did not know was that aside from his heart stopping, he'd come one step closer to death because of a lack of clarity in his code status, which easily could have resulted in us stopping our efforts to revive him.
End-of-life care is a vastly complex topic. One particularly unsettling aspect is the “code status” discussion, in which patients decide whether or not to have invasive measures performed if they are needed during an emergency.
All patients who are admitted to the hospital are asked about their code status, often by a medical intern or resident. (Many have signed forms as well, such as older DNR instructions or the newer MOLST, but they are always asked verbally.)
Asking a patient if they are “Full Code” often goes like this: “Would you want all measures done to keep you alive, including chest compressions, shocks, and medications to keep your heart beating, and/or a breathing tube connected to a ventilator to help you breath if it was required?”
A patient has the option to be “Full Code,” “DNR” (Do Not Resuscitate), “DNI” (Do Not Intubate) or both DNR and DNI. This choice is far from simple, and the way these questions are worded can be a major factor in a patient's choice.
My colleague recalled hearing her senior resident say to a patient, “Would you like us to pursue heroic, invasive measures like putting a tube down your throat or pounding on your chest, or would you like us to let you pass peacefully?” Unsurprisingly, the patient elected the latter.
Some would argue that "pass peacefully" wording is only appropriate for a patient with nothing to gain from invasive measures. The conversation demands something different in a case like Mr. R's, when a patient only needs to be intubated temporarily.
Informing patients of the potential outcomes of their decision is key, yet studies suggest that medical residents mention this in less than one-third of their code discussions.
I have found that when patients truly understand the likely outcomes they face, their decision often — although not always — matches what I would have recommended to them. For many, this entails opting for intubation as long as it is likely to be temporary, and avoiding chest compressions unless there is a moderate to high possibility of significant recovery.
I find expressing compassion helps, as does being straightforward about the prognosis, and offering recommendations to help guide a decision.
Code status discussions truly embody the notion that medicine is an art more than a science. Randomized controlled studies have proven that with specialized preparation and practice, residents can become more thoughtful and responsible in how we approach these delicate conversations.
This is especially important in light of data suggesting that patients' actual wishes can be far from what they list for their code status. In a study focusing on patients who elected to be “DNR/DNI,” over half of them changed their code status to include intubation when presented with specific medical scenarios, and 20 percent changed their response on trying resuscitation for cardiac arrest.
The discrepancy in this study was best explained by limits on the patients’ understanding of how reversible their condition was, and what kind of quality of life they would likely lead afterward. For example, when asked about temporary intubation for life-threatening but reversible airway swelling, 58 percent wanted to change their "DNI"status.
This is a heated debate in modern medicine: Should doctors try to direct these decisions, or simply provide the medical facts without recommendations, allowing the patient to decide?
Each has a potential downside: Directing the decision could infringe on the patient’s autonomy and risks overweighing the physician’s own biases. Providing "just the facts" could mean shirking the doctor’s responsibility to give patients the guidance they may want and need.
What is clear is that though recent years have brought major strides in how doctors and patients alike approach end-of-life conversations, as physicians we still have a ways to go to ensure that our patients are both living and dying as they would hope.
Abraar Karan, M.D., is a resident physician at Brigham and Women’s Hospital and Harvard Medical School (Twitter: @AbraarKaran). The opinions expressed in this article are solely those of the author and do not reflect the views and opinions of Brigham and Women’s Hospital.
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